Title: Implementing the PDH-CPG Across the Deployment Cycle Post OEF/OIF May 2003 (Updated April 2005)
1Implementing the PDH-CPGAcross the Deployment
CyclePost OEF/OIFMay 2003 (Updated April 2005)
- pdhealth_at_amedd.army.mil
- Provider Consult HelpLine 1-866-559-1627
- Patient Call Center HelpLine 1-800-796-9699
2Training Agenda
Introduction and Guideline Overview LTC Charles Engel
Basics of Risk Communication Tim OLeary
Post-Deployment Health Assessment 2796 Enhanced Process COL Jeff Gunzenhauser
PDH CPG Application Lt Col Adkins, LTC Engel, Mr. OLeary
Summary and Questions
3Why Focus On Post-Deployment Health
Care?(Isnt it just routine health care in a
slightly different uniform?)
4because our workplace may be hazardous to health
History Made Overly Simple Before VietnamLife
Limb After VietnamPost-Traumatic Stress
Disorder After Gulf WarToxic Exposure
ConcernsMedically Unexplained Symptoms
5Gulf War Syndrome
- 17 of UK Gulf War Veterans believe they have
Gulf War Syndrome
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8Recent Unexplained Syndromes Involving the
Military, War, Deployment, or Terror
- Dutch peacekeepers in Lebanon (1980s)
- Jungle Disease (Dutch peacekeepers in Cambodia)
- Gulf War Syndrome
- Afghanistan Syndrome (Russia, 1990s)
- Chechnya Syndrome (Russia, 1990s)
- Illnesses after 1992 El Al Airliner crash in
Amsterdam - Illnesses after anthrax vaccination (1990s)
- Dutch peacekeepers in Bosnia (1995-6)
- Canadian peacekeepers in Croatia (late 1990s)
- Balkan War Syndrome
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10Unexplained Physical SymptomsMedicines Dirty
Little Secret
- Specialty Clinical SyndromeOrthopedics Low Back
Pain Patellofemoral Syndrome - Gynecology Chronic Pelvic Pain Premenstrual
Syndrome - ENT Idiopathic Tinnitus
- Neurology Idiopathic Dizziness Chronic Headache
- Urology Chronic Prostatitis Interstitial
Cystitis Urethral Syndrome - Anesthesiology Chronic Pain Syndromes
- Cardiology Atypical Chest Pain Idiopathic
Syncope Mitral Valve Prolapse - Pulmonary Hyperventilation Syndrome
- Endocrinology Hypoglycemia
- Specialty Clinical Syndrome Dentistry
Temporomandibular Disorder - Rheumatology Fibromyalgia Myofascial
Syndrome Silicosis - Internal Medicine Chronic Fatigue Syndrome
- Infect Disease Chronic Lyme Chronic Epstein-Barr
Virus Chronic Brucellosis Chronic Candidiasis - Gastroenterology Irritable Bowel Syndrome
Gastroesophageal Reflux - Physical Medicine Mild Closed Head Injury
- Occupational Multiple Chemical SensitivityMedicin
e Sick Building Syndrome - Military Medicine Gulf War Syndrome
- Psychiatry Somatoform Disorders
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12Institute of Medicine
- Strategy 5 Implement strategies to address
medically unexplained physical symptoms in
populations that have been deployed.
WA, DC, National Academy Press 2000
13A DoD Center of Excellence
- Deployment Health Clinical Center
Mission Improve post-deployment health care
for DoD beneficiaries
Located at Walter Reed Army Medical Center
14How Can We Do Better?
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16DoD-VA CLINICAL PRACTICE GUIDELINE
ONPOST-DEPLOYMENT HEALTH EVALUATION MANAGEMENT
17Post-Deployment Health Clinical Practice
Guideline (PDH-CPG)
- DoD/VA Post-Deployment Health Evaluation and
- Management Clinical Practice Guideline
(PDH-CPG) - Evidence-based guideline for the evaluation and
management of patients with deployment-related
health concerns/conditions in the primary care
setting - Completed by an expert multi-disciplinary,
multi-agency panel in 2001 - Initiated with a worldwide satellite broadcast
January 2002 and distribution of a Tool Kit to
all MTFs - Replaced Comprehensive Clinical Evaluation
Program (CCEP) - No change since 2002 except modified coding
guidance
18PDH-CPG Use Mandated by Health Affairs April
2002
All DoD military treatment facilities should now
be using the Post-Deployment Health Clinical
Practice Guideline the military unique vital
sign question Is the reason for your visit today
related to a deployment? should be asked of
every patientproviders will review and employ,
as needed, this guideline during their
evaluations
19PDH-CPG Components
Primary Care Clinic Visit Military Vital Sign
Screening
Post-Deployment Health Assessment DD Form 2796
PDH-CPG
Symptomatic With No Diagnosis Medically
Unexplained Symptoms Algorithm A2
Symptomatic With Diagnosis Algorithm A3
Asymptomatic Concerned Algorithm A1
20Overview of Guideline Features
- Military-unique vital sign
- Stepped care framework
- Risk communication guidance
- Web-based clinician support
- Longitudinal care emphasis
- Data automation features
- Metrics outcomes monitoring
- Supporting Center of Excellence
21What Is the Military Unique Vital Sign?
- All persons should be asked Is your health
concern today related to a deployment? at every
primary care visit except wellness visits (e.g.
periodic exams and preventive care) - Patient rather than provider determination
- Percentage of positive responses
- lt1 during 2001 testing (Bragg, Lejeune, McGuire)
- 2.8 AD vs 0.2 FM in NQMP study published Dec 04
- 5-8 in current data reviews
22Stepped Risk Communication
23Local Challenges
- Identifying a champion clinical administrative
- Local gap analysis
- Implementing the question?
- Adhering to visit coding?
- Assessing follow-up metrics?
- Local Utilization Management/Informatics support?
- Making provider patient information available
from the toolkit? - Obtaining risk communication training?
- Receiving DHCC News? Medical Early Bird for
those who want to know what patients may be
reading
24Risk Communication Its Relevance for Clinicians
25What is Risk Communication?
- An interactive process of exchange of information
and opinion among individuals, groups, and
institutions. It involves multiple messages
about the nature of risk and other messages, not
strictly about risk, that express concern,
opinions, or reactions to risk messages or to
legal and institutions arrangements for risk
managers. - National Research Council, Committee on Risk
Perception and Communication
26What is Risk Communication?(cont.)
- Building and maintaining relationships based on
the effective exchange of technical and/or
scientific information between concerned
stakeholders about an actual or perceived risk - Risk Communication Team, U.S. Army Center for
Health Promotion and Preventive Medicine
27What is Risk Communication?(cont.)
- A science-based approach for communicating
effectively in - High concern
- Low trust
- Sensitive or
- Controversial situations
- Vincent Covello, Center for Risk Communication
28Gaining Trust and Credibility
- Difficult to gain and easy to lose
- Most important factors are
- Empathy
- Caring
- Personal Commitment
- Honesty
- Openness
- Expertise
29Risk Communication History
- Risk communication dates back to 1980s
- Interact with communities or groups
- Concern about health, safety, or environmental
dangers - Perception of peril to themselves especially to
their children
30Seven Rules of Risk Communication
- Rule 1. Accept and involve the recipient of
information as a legitimate partner - Rule 2. Plan carefully and evaluate performance
- Rule 3. Listen to your audience
- Rule 4. Be honest, frank, and open
31Seven Rules of Risk Communication (cont.)
- Rule 5. Coordinate and collaborate with other
credible sources - Rule 6. Plan for Media influence
- Rule 7. Speak clearly and with compassion
32Narrowing Risk Communication
- Until recently, risk communication was used for
groups and communities - In a clinical setting, risk communication is used
with small groups (e.g., family) or individuals - Building trust and credibility remains crucial
- Fosters a good environment for communicating
sensitive health risk information - Listening is half of communication
33Stepped Risk Communication Strategy
Concerned, Unexplained Symptoms
- Key element of PDH-CPG
- Routine primary care assessment
- routine trust rapport building
- Ascend risk communication
- stairs as outlined above
34Clinical Health Guidelines
- Risk communication is a central part of the
guideline - Routine primary care assessment routine trust
rapport building - Ascend risk communication stairs for
- Unconcerned patient, but recently deployed
- Concerned patient with recognized disease
- Concerned patient who is asymptomatic
- Concerned patient with chronic unexplained
symptoms
35Why Use Risk Communication?
- Allows transmission of relevant accurate health
information - Increases patient provider focus on relevant
health risks - Reduces unnecessary patient distress
36Benefits of Risk Communication
- Improves patient
- Acceptance and adherence to medical advice
- Satisfaction with care
- Confidence in provider their relationship
- Trust in the health care system
- Functioning health behaviors
- Chances of returning to life roles
- Improves provider satisfaction with the process
of delivering care
37What Risks Concern Patients?
- Risk of serious illness
- Risk of various outcomes (e.g., cure, death,
disability) - Risks of medical tests
- Risks of medical treatments
- Risk of workplace or environmental exposures
38Clinical Risk CommunicationE N V I T E
- E-mpathy Listen actively. Confirm what you
hear. Express concern. Convey genuine desire to
assist. - N-on confrontational Subordinate the need to be
right to the obligation to relieve suffering.
Dont engage in arguing with patient. - V-alidate Validate the patients decision to
seek care. - I-nform Offer data that addresses patients
specific concerns presented in an understandable
way. - T-ake Action Describe options. Appropriate
tests/labs. Schedule a follow-up. Research
concerns. Consider consultation or second
opinion, as needed. - E-nlist Cooperation Negotiate an action plan
with the patient rather than imposing one on him
or her.
39Who Needs Risk Communication Expertise?
- Physician
- Nurse
- Desk Clerk/Receptionist
40Risk CommunicationSummary
- Clinical risk communication involves low
trust-high concern situations - Trust and credibility are the heart of
communicating health information to patients - Value your patients views and beliefs
41Post-Deployment Health Clinical Practice
GuidelineTools Application
42Enhanced PDHA Process www.PDHealth.mil
- Guidance for Completing
- DD Form 2796
- PDHA Policies Directives
- Deployment Exposures
- Information
- Redeployment Briefing
- PDHA Training Videos
Toolbox DD2796 Primer
43PDH-CPG Web-Based Toolswww.PDHealth.mil
- PDH Guidelines
- Overview
- Guideline
- Algorithms
- Implementation
- Desk Reference Toolbox
- Tool Kit (Updated by Toolbox)
- CCEP Transition
- Broadcast, 30 Jan 2002
- Supporting Guidelines
- Clinicians Helpline
- 1-866-559-1627
Home Page
PDH Guidelines
44PDH-CPG Desk Reference Toolbox
- Desktop-sized Laminated Box
- Desk Reference Cards
- Compact Discs
- Interactive PDH-CPG
- MEDCOM CD of Other CPGs
- 2 PDH-CPG Training CDs
- Sample Clinician and Patient
- Brochure
- Vaccine Healthcare Centers
- Immunization Tool Kit
-
Contents on www.PDHealth.mil
45Deployment Cycle Support (DCS)Scenario - 12 May
03
- Personnel and situation
- SSG Ira Freedom
- 29 y/o male stationed at Ft Carson
- Married, wife (Patience), 8 y/o son, 4 y/o
daughter - In SWA for 90 days
- In Kuwait and Iraq as part of OEF and OIF
- Saw 2 weeks in combat, including heavy resistance
in Baghdad urban warfare - No significant medical history prior to
deployment - Anticipates redeployment on 15 May
46Deployment Cycle Support (DCS)Scenario - 12 May
03 (cont.)
- SSG Freedoms friends in Iraq
- Formed bond due to similar history
- SSG Reserve, a mobilized reservist
- Mr. Seville, a deployed federal civil service
employee - Ms. Cross, a Red Cross Volunteer
- Ed Itor, an embedded journalist
- All going back on 15 May
- SSG Natalie Guard, a mobilized National Guard
member and SSG Freedoms sister, currently
deployed to Denver airport, will meet him when he
returns
47Redeployment Task In-Theater Medical
Out-Processing
- Task In-Theater Medical Out-processing
- When Within 5 days prior to redeployment
- Who CFLCC (Coalition Forces Land Component
Command) medical assets - Credentialed provider
- Tools
- DD Forms 2766, 2795, 2796
- Paper, fillable PDF, and electronic
- Medical threat debrief - on CHPPM and
PDHealth.mil websites - Med threat info sheet also on both websites
- Medical prophylaxis malaria, others
- Aids Consult helpline, patient education
materials, email CHPPM POC in-theater
48Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign 2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed 2796
Integrate 2796 into DD 2766 Deployable health record, 2766, should be annotated, integrate 2796 with previously completed 2795
49DD Form 2796 Post-Deployment Health Assessment -
Pages 1 2
50DD Form 2796 Post-Deployment Health Assessment
Pages 3 4
51Mental Health Items (DD2796)
- Additional clarification of history directed by
the screening provider's clinical suspicion is
mandated for anyone who reports - A desire for assistance (item 10)
- ANY concerns about self-harm (item 11c)
- A LOT to any of the other depression screening
items (item 11) - Two or more of the acute stress
disorder/post-traumatic stress disorder screening
items (item 12) OR - ANY concerns over loss of control (item 13b)
52Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign DD2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed DD2796
Integrate DD2796 into DD 2766 Deployable health record, DD2766, should be annotated, integrate DD2796 with previously completed DD2795
53Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing16 May, Day
of Return
- Task Home Station Medical Processing
- When Within 5 days post redeployment
- Who Credentialed provider Homer Station, MD
- Assistance LPN Grace, contract screener, or SSG
Whiskey - Tools
- DD Forms 2766, 2796, 2795, SF600 with stamp,
Medical Record, CHCS pick list - Medical threat debriefing - on CHPPM and
PDHealth.mil websites - Medical threat information sheet - also on
website - Medical prophylaxis malaria, others
- Aids Toll-free help line numbers
- Medical consult helpline 1-866-559-1627
- Patient education helpline - especially helpful
for reserve component personnel 1-800-796-9699
54Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing
Medical Debrief Ensure soldier has received medical threat debrief (CHPPM website)
Medical Threat Information Sheet Ensure soldier received two medical threat tri-folds (one medical, one family CHPPM website)
Review medical documentation Review documents with soldier has the DD2796 been completed and signed and inserted into DD2766?
Medical exam with provider, as needed If DD2796 is not completed or present Face-to-face encounter review/complete DD2796 document exposures, physical mental concerns code V70.5_6 () sign
Terminal Prophylaxis If not completed in theater Determine/provide malaria and other prophylaxis needs
Blood and TB Blood sample taken for HIV and Serum Repository TB/PPD immediately and again 90 days post-deployment
Provider referrals For all Determine need from documentation or exam ensure referral to PCM for PDH-CPG based care
Integrate DD2796 and DD2766 Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
55Redeployment Reserve ComponentTask Additional
RC Medical Processing
Medical benefit/ entitlement benefit Ensure each RC soldier receives medical benefit/entitlement brief on www.pdhealth.mil/reservist/personnel and (http//www.defenselink.mil/ra/documents/family/demob.ppt)
Soldier completes DD Form 2697 All personnel released from AD (REFRAD) must complete MEDICAL ASSESSMENT, DD2697 (on pdhealth.mil website)
Health Record Review Provider reviews DD 2697 and other documentation to identify health problems that require additional follow-up
Soldier must actively decline medical exam Physical exam is part of DD2697 default is do the exam unless soldier declines
Complete routine demob medical processing Complete medical processing as in AD scenario refer to PCM as needed for PDH-CPG-based follow-up
LOD required Determine if Line of Duty (LOD) determination is required initiate LOD as needed
ADME requirement Determine if Active Duty Medical Extension is required to clear current health concerns.
Complete documentation Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
56RedeploymentNGO and Civilian, Non-Government
Personnel
- Contractors non-federal workers
- Covered under health insurance of their
contracting company occupational medicine and PM
only if part of contract - Private and network health care providers can get
information about guideline-based care through
help-line and website - Also Tricare network and VA providers can access
info - NGO Personnel Policies
- Red Cross, USO, and other non-government
personnel are not included in the demobilization,
medical processing, or follow-up medical care - Can be exceptions with Secretary of the Army
designee status - Embedded journalists
- A new population
- Not a military health care beneficiary group
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58Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up
- 3. Task Primary Care PDH-CPG DD 2796 Follow-up
- When Should follow ASAP from ID during demob
process - Recommend NLT 7 days of reintegration, may need
immediate - Sick call vs. appointment process for large
groups - Who
- Receptionist - Harmony
- Medical screener/LPN SSG Whiskey or LPN Grace
- Primary Care Manager Dr. Station
- Tools
- SF600 with screening question or stamp
- Toolbox PDH Clinic Visit Desk Reference Card
- DD Form 2844
- Aids
- Web site and algorithms ENVITE mnemonic
- Prior training and role play of situations
59Toolbox Reference Cards PDH Clinic Visit
- Provides guidance for
- training screeners about the
- deployment-related question
- How to ask the question
- Emphasizes that deployment
- is not necessary to have PDH
- concerns
- How to respond to patients
- questions
- Examples of deployments and
- deployment-related concerns or
- conditions
60Optional DD Form 2844 - Post Deployment Medical
Assessment Form and Primer
- Optional form for documenting
- post-deployment medical evaluation
- Form available and can be
- be completed on line at
- www.PDHealth.mil
Toolbox DD 2844 Primer
61Redeployment Task Primary Care PDH-CPG DD
2796 Follow-up (cont.)
- 3. Process Primary Care PDH-CPG DD 2796
Follow-up - SSG Freedom reports, as instructed, to PC on 17
May - Persistent cough, congestion fears SARS (Severe
Acute Respiratory Syndrome) - SSG Guard reports to PC on same day, with same
sx, concerned because of work at the airport - Greeted courteously by Receptionist, Harmony
- Vignette
62Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
- 3. Process Primary Care PDH-CPG DD 2796
Follow-up - Medical screener/LPN SSG Whiskey or LPN Grace
- Asks deployment-related vital sign
- "Is your problem today related to a deployment?"
- Marks yes on stamped SF600 (or pre-printed SF
600 at TMC) - Alerts provider to yes response
- Original DD Form 2796 in permanent medical record
- Color coded forms or folders have been used
- DD Form 2844 on follow-up appointment
63Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
- 3. Process Primary Care PDH-CPG DD 2796
Follow-up - Provider Dr. Station
- Acknowledges that visit is deployment-related
- Reinforces follow-up from DD2796 instructions
- Express appreciation for service compassion for
concerns - Stepped-risk communication model (see guideline)
- ENVITE mnemonic for risk communication
- Info on deployment risks (see PDHealth.mil web
site) - Risk communication takes place throughout
encounter, not just at end - Reviews DD2796 (and DD2844 on follow-up visit)
- Evaluates chief complaint identifies
established diagnosis - Viral respiratory infection (not consistent with
SARS)
64Stepped Risk CommunicationRecognized Disease
65Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
- 3. Process Primary Care PDH-CPG DD 2796
Follow-up - Provider Dr. Station
- Documents deployment-related visit primary code
V70.5_6 - Documents disease-specific diagnosis as secondary
code - Establishes follow-up appointment both IAW
disease specific guideline and for PDH concern
(30 minute PDH appt where DD Form 2844 is used) - Prior to follow-up Researches if SARS was a
potential exposure in area of operations or
during return trip for discussion in follow-up
66Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
- 3. Process Primary Care PDH-CPG DD 2796
Follow-up - Case Management Function
- Adds PDH-CPG Patient to the tracking database
- Ensures follow-up made
- Provides additional patient educational
materials, as requested by patient/provider - Quality controls coding
67Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis
- 3. Definitive Dx Family Member 15 Jun 03
- Patience Freedom brings 8 y/o son, Butch, to PC
- Describes conflict with dad since return from
Iraq son getting into fights at school - Ask screening question military vital sign
- Document screening response and alert provider
- Provider recognizes deployment-related nature
- Provide effective risk communication
- Refer to Behavioral Health provider
- Document deployment V-code and family problem
V-code - Follow-up, track, and manage case
68Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
- 3. Definitive Dx Family Member
- Key points to remember
- Deployment-related problems not limited to
service members or adults - Can be spouse, child, or retiree
- Family affected by stress and also can be exposed
to contaminants, bacteria, etc. brought back by
soldier - Process remains the same
69Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
- 3. Definitive Dx Key Points
- Ensure risk communication in clinic contacts
- Ask screening question military vital sign
- Document screening response and alert provider
- Provider recognizes deployment-related nature
- Triage Identify definitive diagnosis
- Provide effective risk communication
- Document deployment V-code and disease diagnosis
code - Follow-up, track, and manage case
70ICD-9 Coding for Identifiable Disease
- V70.5_ 6
- Deployment-related visit
- plus
- Usual Disease Code
71Asymptomatic Patient with Health Concerns
- Expresses a health concern, but does not exhibit
or describe any discernable illness or injury - Concerns related to
- Illness
- Vaccine or anticipated vaccine or meds
- Exposure or anticipated exposure
- An experience
- News media coverage, internet, etc.
- Can be service member or family member
- Legitimate health care visit
72Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
- Post-deployment Presentation 30 Jun 03
- SSG Freedom presents to clinic
- Describes concerns about DU, read article in
paper - Saw armored vehicle blown-up, no wounds
- Note on wounded processes
- Tools
- SF600 screening question
- Toolbox Desk Reference Cards
- DD Form 2844 on follow-up visit
- Aids
- Fact Sheets
- PDHealth.mil web site and DHCC Deployment Health
Daily News - Provider help-line 1-866-559-1627
73Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
- Post-deployment, Asymptomatic Concerned
- Process
- SSG Whiskey/LPN Grace asks deployment-related
screening question - Records yes, alerts provider to
deployment-related visit - Provider expresses recognition to patient that
the visit is deployment-related and reinforce
decision to make a health care visit to discuss - Employs risk communication through stepped-care
algorithm and ENVITE reminder
74Stepped Risk CommunicationAsymptomatic Concerned
75Worldwide Web Support forPost-Deployment Health
Carewww.PDHealth.mil
- Information on all
- deployments and
- deployment cycle support
- Specific diseases and
- emerging health concerns
- Web-navigable version of
- the PDH-CPG
- Online clinical tools
- News and information library
- Provider education and
- training
- Patient education
76Deployment Health News
- Email newsletter each
- business day
- Deployment-related news
- articles
- To subscribe, sign up at
- www.pdhealth.mil/
- nl_signup.asp
77Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
- Summary Asymptomatic Concerned Key Points
- Ensure risk communication in clinic contacts
- Ask screening question military vital sign
- Document screening response and alert provider
- Provider recognizes deployment-related nature
- Triage Identify Asymptomatic Concerned
- Provide effective risk communication
- Document patient education
- Code V70.5_6 and V65.5
- Research and 30 minute follow-up
- Follow-up, track, and manage case
78Medically Unexplained Symptoms (MUS)
- Physical symptoms that provoke care-seeking, but
have no clinically determined pathogenesis after
an appropriately thorough diagnostic evaluation. - V70.5_ 6 plus ICD-9-CM MUS Code 799.89
- Note ICD-9-CM Guidelines 2005 changed MUS code
from 799.8 to 799.89.
79Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS
- Post-deployment Presentation 15 Sept 03
- SSG Freedom presents to clinic
- Describes fatigue, headache, cant sleep,
episodic rash - Symptoms on and off since return from Iraq
- Tools
- SF600 screening question
- Toolbox Desk Reference Cards
- DD Form 2844 on initial follow-up visit
- Assessment and outcome instruments
- SF36, PHQ, PDCAT
- Aids
- PDHealth.mil web site
- Provider help-line 1-866-559-1627
80Assessment and Outcome Tools
SF-36v2
- SF-36v2 - Health Survey
- Short measure of health-
- related quality of life
- PHQ - Patient Health
- Questionnaire
- Screens and monitors status
- of common health conditions
- PDCAT - Post Deployment
- Health Clinical Assessment Tool
- Measures certain aspects of
- physical and mental health
- Useful in following post-
- deployment health conditions
PHQ
PDCAT
Forms and primers on www.PDHealth.mil
81Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
- Process Medically Unexplained Symptoms
- Ask screening question document alert
provider recognize deployment-related - Use DD Form 2844 to capture more thorough history
- Conduct clinical assessment
- Administer functional assessment and outcome
measure - Use effective risk communication and patient
education materials
82Stepped Risk CommunicationMedically Unexplained
Symptoms
Concerned, Unexplained Symptoms
- Symptom-based patient education
- Consult specialty care
- Deployment Health Clinical Center consult
- Consider Specialized Care Program for chronic
- symptoms
Concerned, Asymptomatic
Concerned, Recognized Disease
- Education
- Web and Print
- 30 minute
- Follow-up appt
- Disease-centered
- patient education
- Disease prognosis
- Disease treatment
- options
Unconcerned, Recently Deployed
Routine rapport trust-building
83VA/DoD Medically UnexplainedSymptoms (MUS)
Clinical Practice Guideline
84Medically Unexplained SymptomsPatient Education
Brochures
Available from the DHCC web site www.PDHealth.mil
Available from the MEDCOM web site
www.qmo.amedd.army.mil
85Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
- Process Medically Unexplained Symptoms
- Refer to MUS-specific Clinical Practice Guideline
- Also at www.pdhealth.mil, Supporting Guidelines
- Additional guidelines Depression, PTSD
- Consider specialty care and second opinions
- Always follow-up, even when referral to specialty
care case management - Case Management
- 30-minute appt for patient education and RC
- Tele-consult DHCC
- For unresolved concerns Consider referral to
DHCC Specialized Care Program for rehabilitative
care - Dont forget to code V70.5_6 Deployment-related
visit plus 799.89 (Ill-defined condition) -
86DHCC Clinical CareSpecialized Care Programs(SCP
Tracks I and II)
- Intensive, 3-week, multidisciplinary,
rehabilitative - program for patients with deployment-related
chronic illness - or Medically Unexplained Symptoms or
post-operational stress - Available to all military members and family
members who - continue to have problems after going through
PDH-CPG based - care at local MTF and meet admission criteria
(e.g., ambulatory, - capable of some exercise) (Track II for
military members only) - Behavioral and self-care strategies and
treatments include
- Physical conditioning
- Patient education
- Counseling
- Nutritional counseling
- Occupational therapy
- Relaxation training
- Cognitive-behavioral therapy
- Exposure therapy
87Deployment Health Clinical Center Resource Center
- DHCC Helpline for Clinicians/Providers
(Administrative and clinical consultation
- Mon-Fri 0730-1630) - US Toll Free 1-866-559-1627
- Local No. 202-356-0907 (DSN 642)
- Outside US DSN 312-642-0907
- DoD Helpline for Veterans and Family Members
(Patient information, referral, advocacy -
Mon-Fri 0730-1630) - US Toll Free 1-800-796-9699
- Local No. 202-782-3577 (DSN 662)
- From Europe Toll Free 00800-8666-8666
- Outside US DSN 312-662-3577
- Email Questions
- pdhealth_at_amedd.army.mil
88Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
- Summary Medically Unexplained Symptoms
- Ask screening question military vital sign
- Document screening response and alert provider
- Use DD Form 2844
- Provider recognizes deployment-related nature
- Evaluate clinically refer to MUS CPG
- Use assessment and outcome tools on pdhealth.mil
- e.g., SF36, PHQ, PDCAT
- Provide effective risk communication
- Code V70.5_6 and 799.89
- Research, 30 minute follow-up
- Consult specialty care DHCC phone consult
DHCC rehabilitative care for chronic MUS - Follow-up, track, and manage case
89Pre-Deployment Phase of Cycle Task Primary
Care PDH-CPG Evaluation and Treatment
- Pre-deployment 1 Nov 03
- SSG Reserve is on reserve drill at Ft Carson
scheduled to be deployed again in
60 days - Reports to Primary Care describes flashbacks of
last combat, inability to sleep, intrusive
thoughts of seeing friend killed in tank
explosion, easily startled, drinking a lot lately - Tools
- All previous PDH-CPG tools
- PTSD screening scale (on web site)
- Risk communication very important at this point
- Process Follow Definitive Diagnosis Algorithm
(A3) - Refer to VHA nearer to his home for treatment
- Key
- MUS is not the same as MH (mental health) concern
- PDH-CPG applies throughout the Deployment Cycle
- VA offers Reserve and Guard care 2 years
post-deployment - Vet Centers available for family counseling
90Post Traumatic Stress DisorderChecklists, Primer
and CPG
- Assesses trauma-related distress
- Self-administered
- 3 Versions
- Civilian Version (PCL-C)
- Military Version (PCL-M)
- Stress Specific Version (PCL-S)
- Available on www.PDHealth.mil
PCL-M
PTSD CPG
PCL Primer
91Deployment Health AssessmentForms and Primers
DD Form 2795
- DD Form 2795, Pre-Deployment
- Health Assessment
- Reviewed by a credentialed provider
- for positive responses
- DD Form 2796, Post-Deployment
- Health Assessment
- Face to face assessment by trained health
- care provider (physician, physician
- assistant, nurse practitioner, independent
- duty corpsman/medical technician)
- Available on www.PDHealth.mil
DD 2795 Primer
DD Form 2796
DD 2796 Primer
92PDH-CPG Training Briefs
- Produced by DHCC
- 7 video modules
- from 7-12 minutes
- Developed for
- medical providers
- and support staff
- Posted on DHCC
- web site
- www.PDHealth.mil
Table of Contents
- Introduction
- Primary Care Screening
- Primary Care Evaluation
- Management Follow-up
- Health Risk Communication
- Coding and Documentation
- PDHA
93Deployment Health ClinicalTraining Series
- Produced by DHCC
- 11 modules from
- 17-47 minutes
- Video, script, slides
- Developed for medical
- providers and support
- staff
- Posted on DHCC web site
- www.PDHealth.mil
Table of Contents
- PDH-CPG
- Introduction/Overview
- Screening/Evaluation
- Management/Follow-up
- Risk Communication
- Coding/Documentation
- PDHA Process
- Emerging Health Concerns
- Suicide
- Malaria
- Depleted Uranium
- Leishmaniasis
- Vaccine Safety
94Unlesswars are fought solely by machines, the
human cost of warfare will remain high. The
troops mustbe given a commitment for all
necessary care for war-related illness.
Straus SE Lancet 1999 353162-3
95Questions, Information,Assistance
DoD Deployment Health Clinical Center
Walter Reed Army Medical Center Building 2,
Room 3G04 6900 Georgia Ave, NW Washington, DC
20307-5001 E-mail
pdhealth_at_na.amedd.army.mil Website
www.PDHealth.mil
202-782-6563 DSN662
Provider Helpline 1-866-559-1627
Patient Helpline 1-800-796-9699